All sections to be completed in full

APPLICATION FORM
Grade VIII Quality & Safety Manager
Community Healthcare East
Ref: CHE472021

 Please ensure you fully read and understand the ‘Additional Campaign Information for Candidates – Grade VIII
Quality & Safety Manager, document specific to this campaign that is available on
https://www.hse.ie/eng/staff/jobs/job-search/management-admin
 Please ensure you read in full, the instructions for the completion of this application form and complete all areas,
including the supplementary questions section, in full. Failure to complete all areas of the application form may
result in you not being brought forward to the interview stage of the selection process.
 Candidates should note that applications emailed will not be accepted. We recommend that applicants wishing to
return an application by post should allow a minimum of 2 days for their application to reach Emma Collins at The
Human Resources Department, Block B, Civic Centre, Main Street Bray, Co. Wicklow by the closing time of
Thursday 1st July 2021. Applications will not be accepted after this date and time, no exceptions will be made
 It is preferable that Application Forms are typed.
 Applications must be submitted by post.
 In relation to details of employment, if the space provided is insufficient, please attach additional pages ensuring
to use the same format.
 Please read the Job Specification which provides useful information about the requirements of this post.
 Should you be invited for interview, you may take a 'hard' copy (or 'paper' copy) of your application form with you.
Mobile devices are not permitted for use during your interview.
 The Health Service Executive will run this campaign in compliance with the Code of Practice prepared by the
Commission for Public Service Appointments (CPSA). The Codes of Practice are available on the CPSA website
www.cpsa.ie. Further information is also available in the Additional Campaign Information document available on
http://www.hse.ie/eng/staff/jobs/job_search/.
 The Health Service Executive is an Equal Opportunities Employer.
 The Health Service Executive recognises its responsibilities under the Data Protection Acts 1988 and 2003 and
the Freedom of Information Act 2014.

Please return completed application form to:

Postal: Ms. Emma Collins, Human Resource Department, Block B, Civic Centre, Main Street,
Bray, Co. Wicklow
Closing date for applications: Thursday 1st July 2021
It is anticipated that interviews will be held: Due to the urgent requirement of this post
interviews may take place as soon as possible once the closing date has passed. This
means that you may be called forward for interview at short notice.

1
 APPLICANT DETAILS

Grade VIII Quality & Safety Manager, Community

Position Applied For: Healthcare East
Campaign Reference No.: CHE472021

Personal Details

First Name:
Last Name:

Postal Address for Correspondence:

Mobile Telephone (mandatory):

Contact Telephone No. 2:

Email Address (mandatory):

(You may provide more than one)

Drivers Licence:
(Please state type & category)

European Economic Area (EEA)

Are you an EEA (European Economic Area) National? Yes No

If you are a non-EEA citizen you must provide the requested documentation to support your application .
Please see Appendix 2 of the ‘Additional Campaign Information’ document for further information and for a definition
of an EEA National.

In order to help us gauge the efficiency of our advertising strategy for this campaign, we would appreciate if you
indicated below where you saw the campaign advertised. +

HSE Website
Word of mouth – my manager/colleague
Notification from HSE Talent Pool
Public Jobs
Other – please say which

+ More than one indication is allowed.

2
1. Superannuation Schemes

Please indicate in the table below if you are currently in receipt of a Voluntary Early Retirement or Ill Health Early
Retirement Pension from any of the Public Health Superannuation Schemes or any other Public Sector
Superannuation Scheme listed at 1-5 below.

Yes No
1. Local Government Superannuation Scheme (LGSS)
2. Health Service Executive Employee Superannuation Scheme
3. Voluntary Hospital’s Superannuation Scheme (VHSS)
4. Nominated Health Agencies Superannuation Scheme (NHASS)
5. Other Public Service Superannuation Scheme

If yes, please provide further details:

_______________________________________________________

If you have answered ‘yes’ in relation to being in receipt of a Voluntary Early Retirement or Ill Health Early Retirement
pension from any of the above Superannuation Schemes please refer to Appendix 4 in ‘Additional Campaign
Information’ for further details.

2. Current Contractual Status

 I am currently a HSE employee* Yes No

 I am currently a Tusla employee* Yes No

Please tick the HSE/Tusla Area in which you work

Dublin Mid Leinster South

Dublin North East West

If you answered yes to the above question, please choose the option below which best matches your current
contractual status:

 I have a permanent contract

or
 I have a temporary contract

*HSE / Tusla Employee = you are a direct employee of the HSE or Tusla and not in a post funded or partially funded by the HSE or
Tusla

3. Proficiency in Irish

Candidates will be afforded the added opportunity to demonstrate their ability to perform the duties of the office
through Irish. This assessment will be on a pass/fail basis and will not disturb the marks awarded in the selection
process. Where vacancies arise for which proficiency in Irish is a management requirement, the HSE will offer such
posts in order of merit to candidates who have successfully passed the Irish assessment. Please indicate if you wish
to undertake an Irish assessment exam.

Yes / No

3
 EDUCATIONAL ACHIEVEMENTS

Please list your second level and any (additional) third level educational achievements.

Dates Educational Conferring Course of Study Qualification Grades Achieved

Institution Body Achieved
From/To

4
 CAREER OVERVIEW

Please ensure your full career history is clearly outlined below (e.g. if you took a career break, spent time out of work,
please include this information so there are no gaps in your career history from when you left full-time education to
present date).

From To Title Employer

Detailed Career History - please begin by listing the most recent first.

Job Title:
Grade/ Management Level (if applicable):

Employer(s) & Department Name:

From (00/00): To(00/00):

Main Roles & Responsibilities:

Job Title:
Grade/ Management Level (if applicable):

Employer(s) & Department Name:

From (00/00): To(00/00):

Main Roles & Responsibilities:

5
Job Title:
Grade/ Management Level (if applicable):

Employer(s) & Department Name:

From (00/00): To(00/00):

Main Roles & Responsibilities:

Job Title:
Grade/ Management Level (if applicable):

Employer(s) & Department Name:

From (00/00): To(00/00):

Main Roles & Responsibilities:

Job Title:
Grade/ Management Level (if applicable):

Employer(s) & Department Name:

From (00/00): To(00/00):

Main Roles & Responsibilities:

6
 ELIGIBILITY CRITERIA

In this area we ask you to focus on your experience to date that is relevant to the role of Grade VIII Quality &
Safety Manager. Please indicate below how your professional experience meets the eligibility criteria for this
post. This section will be assessed by a board of Senior Managers to consider your experience as it is relev-
ant to the eligibility criteria. Information you provide in this section and in other areas of the application form
may be used as part of a short listing exercise and may be discussed in more depth at interview, should you
be called to one.

 Please provide clear, detailed answers that demonstrate the depth and breadth of your experience in the
areas below, reflective of the requirements of this post.

 Each section below must be completed. As you complete each section we recognise there will be an
overlap in the employer and date periods.

 We would like to highlight to you that if you omit information in this section pertinent to the eligibility
criteria your application will be deemed ineligible and you will subsequently not be called forward to
interview.

1. Please demonstrate your operational experience in managing and/or delivering a complex service
within the area of health or social care as relevant to the role.

Date(s) from – Date(s) to Employer(s) & Department Name

7
 2. Please demonstrate your experience of delivering change in a complex environment, as relevant to the
role.

Date(s) from – Date(s) to Employer(s) & Department Name

8
 3. Please demonstrate your experience in relationship/team management and working collaboratively
with multiple internal and external stakeholders, as relevant to the role.

Date(s) from – Date(s) to Employer(s) & Department Name

9
 4. Please demonstrate your requisite knowledge and ability including a high standard of suitability and
management ability for the proper discharge of the duties of the office.

Date(s) from – Date(s) to Employer(s) & Department Name

10
Candidate Name: ________________________ Candidate Reference No: ______________________

Organisation Chart

We would appreciate it if you would forward a copy of an organisation chart indicating your current position
within the Senior Management team in your organisation.

There is no fixed requirement here in terms of format, and we will accept whatever format is convenient for
yourself (e.g. an existing published chart from your organisations website / annual report), but we would
emphasise that the selection panel have requested this to help them understand your level within your cur-
rent / most recent organisation and your positioning relative to other senior managers.

If you do not have access to a corporate chart you may find the template below useful.

If you are independent or have not been part of an organisation recently, a chart is not necessary.

Organisation Chart Template

11
General Declaration

It is important that you read this Declaration carefully.

Part 1: Obligations Placed on Candidates who participate in The Recruitment Process.

The Public Service Management (Recruitment and Appointments) Act 2004 and Public Service Management
(Recruitment and Appointments) Amendment Act 2013 makes very specific provisions in relation to the responsibilities
placed on candidates who participate in recruitment campaigns and these are detailed in Section 4 of the Code of
Practice issued under the Act.
These obligations are as follows:
Any canvassing by or on behalf of candidates shall result in disqualification and exclusion from the recruitment
process. Candidates shall not:
 knowingly or recklessly make a false or a misleading application
 knowingly or recklessly provide false information or documentation
 canvass any person with or without inducements
 impersonate a candidate at any stage of the process
 knowingly or maliciously obstruct or interfere with the recruitment process
 knowingly and without lawful authority take any action that could result in the compromising of any test material or
of any evaluation of it
 interfere with or compromise the process in any way

Any person who contravenes the above provisions, or who assists another person in contravening the above
provisions, shall be guilty of an offence.

It is the policy of the HSE to report any such above contraventions to An Garda Siochána.

In addition, where a person found guilty of an offence was or is a candidate at a recruitment / selection process, then,
in accordance with the Public Service Management (Recruitment and Appointments) Act 2004 and Public Service
Management (Recruitment and Appointments) Amendment Act 2013.

 where he / she has not been appointed to a post, he / shall be disqualified as a candidate; and
 where he / she has been appointed as a result of that process, he / she shall forfeit that appointment

Part 2
Declaration: “I declare that to the best of my knowledge and belief there is nothing in relation to my conduct,
character or personal background of any nature that would adversely affect the position of trust in which I would be
placed by virtue of my appointment to this position. I hereby confirm my irrevocable consent to the Health Service
Executive to the making of such enquiries, as the Health Service Executive deems necessary in respect of my
suitability for the post in respect of which this application is made.

I hereby accept and confirm the entitlement of the Health Service Executive to reject my application or terminate my
employment (in the event of a contract of employment having been entered into) if I have omitted to furnish the Health
Service Executive with any information relevant to my application or to my continued employment with the Health
Service Executive or where I have made any false statement or misrepresentation relevant to this application or my
continuing employment with the Health Service Executive.

Furthermore, I hereby declare that all the particulars furnished in connection with this application are true, and that I
am aware of the qualifications and particulars for this position. I understand that I may be required to submit
documentary evidence in support of any particulars given by me on my Application Form. I understand that any false
or misleading information submitted by me will render me liable to automatic disqualification or render me liable to
dismissal, if employed.”

Signed:

(Name of Applicant)
Date:

NB: If you are submitting your application form via email we will accept the application form unsigned but you will be
required to sign the Declaration at interview should you be invited to one. Failure to sign this declaration at interview
will render it invalid.

12
 REFERENCES

Please give three referees (including your current employer). Please ensure that the referees you provide are from a
professional perspective. We retain the right to contact all previous employers.

Do you wish us to contact you prior to contacting your referees? Yes / No

1. Name and Job Title of Referee:

Dates From-To (MM/YY- MM/YY):

Professional Relationship to Candidate:

Postal Address:

Telephone Contact Details: Mobile: Landline:

Email Address:

2. Name and Job Title of Referee:

Dates From-To (MM/YY- MM/YY):

Professional Relationship to Candidate:

Postal Address:

Telephone Contact Details: Mobile: Landline:

Email Address:

3. Name and Job Title of Referee:

Dates From-To (MM/YY- MM/YY):

Professional Relationship to Candidate:

Postal Address:

Telephone Contact Details: Mobile: Landline:

Email Address:

13
 APPLICANT CHECKLIST

If all required details / documentation (as below) are not submitted with your application we will be unable to process
your application to the next stage of the process i.e. short listing / interview.

Mobile Telephone Number

Email Address
Postal Address

That the information you have provided in the Qualification/

Eligibility Criteria section clearly shows how your experience
matches the requirements. Dates should be clearly indicated i.e.
DD/MM/YY, qualification titles etc. Mandatory
Work Permit Documentation (if relevant to non-EEA applicants).
Please refer to Appendix 2 of the Additional Campaign information
document for details of documentation required.

Application is submitted by the closing date and time and that you
have used the campaign reference in the subject line of your email.

That you have downloaded and saved the Job Specification and Additional Campaign Information for
future reference.

14